Provider Demographics
NPI:1720579733
Name:SHBEB, AHMAD (DDS)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:SHBEB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8283 BYMDWS RD E APT 1318
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3060
Mailing Address - Country:US
Mailing Address - Phone:313-629-8117
Mailing Address - Fax:
Practice Address - Street 1:857 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5785
Practice Address - Country:US
Practice Address - Phone:386-755-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253591223G0001X
MA390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA26165285Medicaid